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Case ID: 1
Created: 28 July 2011

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Station 4 ( Counselling Station):

Subject Mr Robert- 25 years old gentleman

You are required to see Mr Robert's father. Mr Robert is from United Kingdom,came to visit Penang, Malaysia 2 weeks ago and met with an car accident. He sustained severe head injury and has been ventilated in the ICU for almost 2 weeks. Your ICU doctor has informed you that Mr Robert has no spontaneous breathing even the sedation has been off a few days ago. First brain test conducted this morning confirmed that Mr Robert is brain dead.They noticed from Mr Robert's friends as well that he pledged to be an organ donor when he joined an organ donation awareness programme in UK a few months ago.

Your task is to explain to Mr Robert's father about brain dead and ask his permission for organ donation.


A Gift Of Life


Yes, you are right. Malaysia is still considered the country having the lowest organ donation rate in the World. Currently there are more than 14,000 End Stage Renal Failure (ESRF) patients waiting for kidney transplantation. According to the latest Malaysian National Transplant Resource Centre Website, up to July 2011 this year, there are only a total of 18 organ donors. Lesson to be learned here, it is a very popular topic if you plan to sit for MRCP PACES in Malaysia or Singapore.

Certainly to tackle this type of case, you need to have the following skills and knowledge,

arrow1) The skill of starting a conversation with Mr Robert's father and later explain to him the meaning of brain death ( Always show empathy and slowly leads the conversation to brain death discussion)

For example, I might start the conversation as below,

" Hi, Mr Robert, I was told that you just reached Penang from London this morning. You must be very tired right now, I am so sorry I need to arrange this meeting with you to discuss about your son's condition in ICU."

" I think you must have seen your son this morning in ICU. Did anyone so far inform you about his progress in ICU?" etc

From the conversation, you will later find out how much Mr Robert knows about his son's condition and how can you procced the conversation.

" Mr Robert, as I was told by my anesthesiologist colleague, they have weaned off the medication that put your son into deep sleep but unfortunately he does not wake up even this medication was off almost 5 days ago!"

After this sentence, you will anticipate he asks you the reason behind this, that opens the opportunity for you to explain to him about brain death.

arrow2) Understanding about organ donation.Certainly some patients' family members might be worried about disfigurement to the body of the deceased, pain to the deceased etc.

Be prepared to answer about how the diagnosis of brain death is made. Also try your best to answer all questions possibly posed by Mr Robert's father.

arrow3) Knowledge about organ and tissue donation.

You might want to find out about some contraindications for organ donation such as fulminant septicemia, metastatic maliganancy etc

arrow4) Knowledge about ways to increase donation rate in the country.

I think it is rather a common sense question. Creating awareness, publicity by the media etc.However, try to mention a few other methods such as 'opt-out' model practised by Singapore, paired exchange, transplantation across ABO, donation after cardiac death etc.

Common Questions in MRCP PACES,

1) What do you understand by ' donation after cardiac death'?

2) How to make a diagnosis of brain death?

Extra points:

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Case ID:2
Created: 28 July 2011

Breaking trial in Clinical Medicine/Nephrology



Background History:

    Tumour lysis syndrome is a hematology emergency that you always encounter during your medical/hematology rotation. Dr Howard in his article recently published in New England Journal of Medicine ( NEJM) summarised beautifully this syndrome and highlighted the principles managing patients with Tumour lysis syndrome.

Click HERE to download the article

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